Non-Specific Neck Pain - the Case for Specific Treatment

Introduction

Neck pain and low back pain were the leading cause of global disability in 2015 in most countries.[1] In most instances, neck pain is considered to be non-specific as there is no known patho-anatomical cause.[2]

However, according to Professor Jull, there are inherent risks in using the “non-specific” label for neck pain.[2] These risks include:

  • Physiotherapists failing to appreciate variations within and between the domains of the biopsychosocial framework for individual patients
  • Physiotherapists prescribing generic treatment across all domains of the biopsychosocial framework rather than considering each patient’s unique presentation

What do we know about neck pain?

Most people get better from an episode of neck pain. Moreover, education and advice are usually sufficient for people who have neck pain.[3] However, 50-75% of people who experience neck pain will experience another episode within 1-5 years or they will have continuing neck pain.[4]

Jull, therefore, poses the question of whether reducing pain during a specific episode of neck pain should be our main aim. She suggests that focusing only on pain relief fails to consider the burden generated by repeat acute events over the years.[2] These include:

  • Loss of quality of life
  • Loss of productivity
  • Cost of treatments
  • Cost of harm (ie side effects of drug treatments)

Like any condition, it is important to consider the biopsychosocial model when assessing and treating patients with neck pain.

The Psychological Domain

Pain is a significant sensory and emotional experience and patients with neck pain may present with a number of psychological symptoms [2], including depression or anxiety.[5][6]

However, there is no strong evidence that psychological interventions for acute or chronic neck pain or whiplash result in clinically relevant changes to neck pain and disability.[7]

Why aren't psychological interventions helping?

Jull suggests that these interventions are failing in part because they are not being applied specifically - ie not everyone will respond to the same intervention and, in some instances, applying a psychological intervention may have no effect.[2]

While recent research has shown a link between neck pain and psychological symptoms, these symptoms are more significant in some patients than others. A study by Park and Kim found that 28% of patients with chronic neck pain attending a pain clinic were depressed.[8] Thus 72% had no symptoms of depression al all.[2]

Moreover, a study by Nazari et al. found that psychological responses often decrease as pain decreases.[5] In fact, many psychological symptoms or emotions are a natural response to injury and pain, so as Jull notes we should not pathologise normal human reactions.[2]

Thus, while it is important to recognise psychological features and try to incorporate psychological awareness into our treatment, it doesn’t mean that this should be our primary focus.[4] However, it is essential to recognise the need to refer on to mental health practitioners if it is warranted.[2]

The Biological Domain

Manual therapy

Manual examination and therapy have been de-popularised in some quarters, but according to Jull, the scientific basis for this is poor.  While there are many things that manual therapy cannot do (ie it has little effect on neuromuscular and sensorimotor function), it remains useful.[2]

  • Manual examination is vital in the diagnosis of neck pain. The Flexion Rotation Test, for instance, has face validity,[9] as well as 90% sensitivity and 88% specificity to distinguish cervicogenic headache with C1-2 dysfunction.[10]
  • Similarly, a cluster of three tests has even shown to be sensitive (94%) and specific (84%) means of diagnosing cervical facet joint dysfunction. These tests are:
    • the extension-rotation test
    • manual spinal examination
    • palpation for segmental tenderness[11]
  • Manual therapy is effective in reducing neck pain as a single modality or as part of a multimodal programme[2]

However, like psychological interventions, manual assessment/therapy needs to be specific. A lack of skills in these areas, risk non-specific diagnosis and treatment for neck pain.[2]

Neuromuscular and sensorimotor function

Neck pain causes many changes in neuromuscular and sensorimotor function, which do not automatically resolve as the pain diminishes.[2] This has been demonstrated in patients with whiplash,[12] cervicogenic headache[13] and in patients with cervical vertigo.[14]

Exercise is essential if these impairments are to be addressed. However, the research to date has not provided a clear picture of which exercises are most effective. Quite different exercise programmes have all been shown to reduce headache and neck pain.[2] However, if the primary outcome focuses on restoring muscle function in order to prevent further episodes of neck pain, then the choice of exercise is important.[2]

Impaired muscle function in neck pain

Patients with neck pain have reduced strength, decreased endurance and greater fatiguability.[2] Changes in motor control are also evident. For instance:

  • There is a tendency for greater dysfunction in the deep cervical extensors.[15]
  • Christensen et al. found that neck pain causes some reorganisation in axio-scapular muscle activity - for instance, with arm elevation tasks, there is delayed activity of serratus anterior and reduced duration of muscle activation of serratus anterior during arm elevation and lowering.[16]
  • Falla et al. found that there are signification variations in muscle activation in the deep neck flexors during the craniocervical flexion test in neck pain patients versus healthy participants.[17]

These changes are significant when considering the prevention of recurrent neck pain. When looking at the physiological effects of different modes of exercise (including motor relearning training, endurance/strength training and mobility training), motor control/motor relearning exercises improved muscle action in the cranio-cervical flexion test (CCFT). Strength and mobility training had no effect. Motor learning improved the timing of the deep cervical flexors, but it had no effect on strength and endurance. All interventions improved range of motion.[2]

Reducing recurrence of neck pain

It is important to know the specific types of exercises needed for different muscle impairments and different sensorimotor impairments. However, reducing recurrence has not been the main objective in previous randomised control trials (RCTs). To truly look at reducing recurrence rates, we need RCTs that test the effect of neuromuscular and sensorimotor retraining that is specific to the impairment.[2]

The Social Domain

Computer use has been linked with an increasing prevalence of neck pain. More than 6 hours of computer use per day increases a person’s risk of developing neck pain.[18] Similarly, when using a tablet, the mechanical demand on the extensor muscles increases 3-5 times when compared to a neutral posture.[19] However, neck pain is not specific to any particular profession. Time in the workplace alone seems to increase the tendency to develop moderate to severe neck pain in some young adults.[20]

Reducing the burden of non-specific neck pain with preventative exercise

To be adopted, exercises need to be:

  • safe, short, simple and effective
  • incorporated into daily activities
  • suitable for all ages.[2]

Jull recommends primary prevention should look at activating and training endurance capacity of postural muscles:[2]

  • Bring spine to a neutral position to take the load off the joints
  • Reciprocal relaxation of levator scapulae (NB this occurs when the scapular depressors are contracted)[21]
    • To be completed 2 x per hour - correct posture and hold for 10 seconds
  • Mobilising exercise - archery exercise


References

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  3. Bier, J, Scholten-Peeters, G, Staal, JB, Pool, J, Tulder, M, Beekman, E et al. Clinical Practice Guideline for Physical Therapy Assessment and Treatment in Patients With Nonspecific Neck Pain. Physical Therapy. 2018; 98(3): 162-171.
  4. 4.0 4.1 Carroll, LJ, Hogg-Johnson, S, van der Velde, G, Haldeman S, Holm, LW, Carragee, EJ et al. Course and prognostic factors for neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008; 33(4 Suppl): S77-82.
  5. 5.0 5.1 Nazari, G., Bobos, P, Billis E, MacDermid JC. Cervical flexor muscle training reduces pain, anxiety, and depression levels in patients with chronic neck pain by a clinically important amount: A prospective cohort study. Physiother Res Int. 2018; 23(3): e1712.
  6. Falla, D, Peolsson, A, Peterson, G, Ludvigsson, ML, Soldini, E, Schneebeli, A et al. Perceived pain extent is associated with disability, depression and self-efficacy in individuals with whiplash-associated disorders. Eur J Pain. 2016; 20(9): 1490-501.
  7. Monticone, M, Ambrosini E, Cedraschi C, Rocca B, Fiorentini, R, Restelli, M. Cognitive-behavioural treatment for subacute and chronic neck pain (Cochrane review). Cochrane Database Syst Rev. 2015: CD10664
  8. Park, SD, Kim, SY. Clinical feasibility of cervical exercise to improve neck pain, body function, and psychosocial factors in patients with post-traumatic stress disorder: a randomized controlled trial. J Phys Ther Sci. 2015; 27(5): 1369-1372.
  9. Takasaki, H, Hall, T, Oshiro, S, Kaneko, S, Ikemoto, Y, Jull G. 2011. Normal kinematics of the upper cervical spine during the Flexion-Rotation Test - In vivo measurements using magnetic resonance imaging. Man Ther. 2011;16(2): 167-71.
  10. Hall, TM, Robinson, KW, Fujinawa, O, Akasaka, K. Pyne, EA. Intertester reliability and diagnostic validity of the cervical flexion-rotation test. J Manipulative Physiol Ther. 2008;31(4): 293-300.
  11. Schneider, GM, Jull, G, Thomas K, Smith, A, Emery, C, Faris, P et al. Derivation of a clinical decision guide in the diagnosis of cervical facet joint pain. Arch Phys Med Rehabil. 2014; 95(9): 1695-701.
  12. Sterling, M, Jull, G, Vicenzino B, Kenardy, J, Darnell, R. Development of motor system dysfunction following whiplash injury. Pain. 2003; 103(1-2): 65-73.
  13. Jull, G, Trott, P, Potter, H, Zito, G, Niere, K, Shirley, D et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002; 27(17): 1835-43.
  14. Reid, SA, Rivett, DA, Katekar, MG, Callister, R. Comparison of Mulligan Sustained Natural Apophyseal Glides and Maitland Mobilizations for treatment of cervicogenic dizziness: a randomized controlled trial. Physical Therapy. 2014; 94(4): 466-476.
  15. O;Leary, S, Cagnie, B, Reeve, A, Jull, G, Elliot JM. Is there altered activity of the extensor muscles in chronic mechanical neck pain? A functional magnetic resonance imaging study. Arch Phys Med Rehabil. 2011; 92: 929-34.
  16. Christensen, SW, Hirata, RP, Graven-Nielsen. The effect of experimental neck pain on pressure pain sensitivity and axioscapular motor control. J Pain. 2015; 16(4): 367-79.
  17. Falla, DL, Jull GA, Hodges, PW. Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test. Spine. 2004; 29(19).: 2108-14.
  18. Blatter, BM, Bongers, PM. Duration of computer use and mouse use in relation to musculoskeletal disorders of neck or upper limb. International Journal of Industrial Ergonomics. 2002; 30(4-5): 295-306.
  19. Vasavada, A, Nevins, D, Monda, S, Hughes, E, Lin, D. Gravitational demand on the neck musculature during tablet computer use. Ergonomics. 2015; 58(6): 1-15.
  20. Hanvold, TN, Waersten, M, Mengshoel, A, Bjertness, E, Twisk, J, Veiersted, K. A longitudinal study on risk factors for neck and shoulder pain among young adults in the transition from technical school to working life. Scand J of Work Environ Health. 2014;40(6): 597-609.
  21. Jull, G, Falla, D, Treleaven, J, O'Leary. Management of neck pain disorders e-book: A research informed approach. Edinburgh: Elsevier, 2019.
  22. Better Exercise Physiology. Pilates Exercises: Bow and Arrow Stretch for upper back tightness. October 2014. Available from: https://www.youtube.com/watch?v=CNPBQwm14HA